Measuring Rights: Counseling, Informed Choice, and Decision Making
The fundamental right of women and girls to decide, freely and for themselves, whether, when, and how many children to have is central to the vision and goals of FP2020.
Four years into the initiative, many efforts are underway to ensure that family planning programs are built on and respect rights principles. Core Indicators 14, 15, and 16 measure facets of empowerment, informed choice, and quality of care, all of which are important aspects of rights-based family planning.
Core Indicator 16 (Estimate Table 16) measures the percentage of women who make family planning decisions either by themselves or jointly with their husbands or partners. Across countries that have had surveys since 2012, the indicator shows a high level of women’s participation in contraceptive decision-making, ranging from 71% in Comoros to 98% in Egypt and Rwanda.
It is important to note that in more than half of these countries (15 of the 29) at least 1 in 10 female users reported that they were not involved in important choices, such as whether and when to use contraceptives and what method to use. These data suggest that in many countries work remains to be done to ensure that all women and girls have the ability to make contraceptive decisions voluntarily and free of discrimination, coercion, or violence.
The results from Indicator 16, however, paint an incomplete picture of empowerment. Given that the indicator scores are fairly high and vary little across country and year, the indicator is likely not capturing many of the challenges related to decision making that contraceptive users face. Furthermore, Indicator 16 only measures the decision-making power of women who are currently using a method and gives no insight into the experiences of women who are not using a method or how that decision was made. Other studies indicate some of the barriers that these women face, and a 2016 Guttmacher study on non-use indicates that opposition by partners or others is a challenge for married women with an unmet need for family planning.23 On average, 9% of women in countries with available data cited opposition by partners or others as a reason for their contraceptive non-use, with the proportion as high as 27% in Timor-Leste and as low as 2% in Cambodia and Peru.
The quality of family planning counseling and services available to women is also an underlying factor affecting contraceptive use. Proper counseling provides women and girls with medically accurate information about their bodies and contraceptive options, and enables them to explore and choose among a range of methods as their sexual and reproductive health needs evolve over time. Counseling also helps contraceptive users understand potential side effects and find their preferred method.
Core Indicator 14 (Estimate Table 14), the Method Information Index (MII), serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The MII is a summary measure constructed from three questions asked of current contraceptive users about the occasion when they obtained their current method:
- 1. Were you informed about other methods?
- 2. Were you informed about side effects?
- 3. Were you told what to do if you experienced side effects?
The MII value is the percentage of respondents answering “yes” to all three questions. For countries with sufficient data since 2012, we report the overall MII value, the MII value by method, and the percentage of women who positively answered each question.
In 2016, MII values range from 13.5% in Pakistan24 to 71.8% in Zambia. Users of implants and IUDs tend to receive more information regarding their methods, and on the whole, women tend to be told of other methods more often than they are informed of side effects or how to handle them. A closer look into countries and methods with low MII values is needed to understand why providers are not sharing the information that is critical to informed consent.
Results from the 2016 Guttmacher study suggest that women are not being provided with the information they need to make informed choices about using contraceptives. It found that many women who do not use contraceptives because of infrequent sex or amenorrhea/breastfeeding—two of the most commonly cited reasons—may be underestimating their risk of becoming pregnant. For example, significant proportions of women who cited infrequent sex as a reason for non-use were sexually active in the last month. Similarly, the majority of women who cited postpartum amenorrhea and/or breastfeeding had given birth more than six months ago.
The Guttmacher study also found that a large proportion of women not using contraceptives are concerned about side effects or health risks. In 21 of the 52 countries included in the study, fear of side effects was the most common factor driving nonuse. In most countries, it accounted for between 20 and 33 percent of women who wanted to avoid pregnancy but were not using contraceptives. These women are significantly more likely to have already used a modern method than women who cite other reasons for nonuse, suggesting that these fears come from women’s actual experience with methods and service providers. Whether these fears stem from misinformation or real health risks associated with a given method, their pervasiveness highlights the importance of family planning counseling to address women’s concerns and to assist them in selecting the method they feel is right for them.
A Closer Look: Contraceptive Non-Use
It is important to remember that a woman’s decision to use contraception is shaped by a range of socio-economic, cultural, and geographic factors, and that the results of the Guttmacher study on non-use, which reflect answers to a single DHS question, may not fully capture this complexity. As its authors note, the study does not capture all reasons cited for non-use, rank these reasons by importance,
or offer insight into the ways that multiple factors work in tandem to hinder use. A closer look through qualitative research and in-depth quantitative studies is needed to more fully understand women’s experiences and variation across and within countries, and to identify interventions that can effectively help women and girls fully exercise their reproductive rights.
Data from Core Indicator 15 (Estimate Table 15), the proportion of women who received any kind of family planning information in the last year, either from a health worker in a facility or the field, also signal that many countries will need to dramatically expand family planning counseling, information, education, and communications if they hope to enable more women and girls to make informed contraceptive choices by 2020. Core Indicator 15 shows that across countries with available data, this percentage varies widely—from 6.6% in Guinea to 52.4% in Liberia.
The proportion can also vary by wealth quintile within countries. In some countries, such as DR Congo and Yemen, the proportion among the wealthiest quintile who report receiving information was larger than that of the poorest women. In others, including the Philippines, Togo, and Haiti, a larger percentage of the poorest women had received information compared to wealthy women. These numbers must be interpreted in context, as not all women want or need family planning counseling. But in more than half (15 out of 27) of the countries with data for this indicator, at least 75% of women reported not receiving any information on family planning in the last year.
While Core Indicators 14, 15, and 16 are limited in what they each reveal, they can paint a fuller picture when examined alongside each other. In Zambia, 72% of contraceptive users reported that they had been informed about side effects and alternatives to their current method—the highest proportion of women in any country. However, relatively lower proportions of women compared to other countries received information about family planning (30%) or reported that they alone or with their partner made the decision to use contraceptives (83%). Together these suggest that while most current users have been equipped with knowledge that is critical to informed choice, they may not be empowered to make contraceptive decisions for themselves.
In contrast, almost 95% of women in Indonesia made decisions about family planning by themselves or with a partner, but they may not have made those decisions based on full information about method options and side effects. Only 30% of women reported receiving information on other methods, side effects, and what to do about side effects.
Several FP2020 partners are involved in research and program efforts to operationalize rights and empowerment principles at the service delivery point—including offering improved counseling—and to measure the impact of these principles on contraceptive use. These efforts are critical to reducing discontinuation rates and sustaining and expanding contraceptive use through 2020 and beyond.
A Closer Look: The National Composite Index for Family Planning
The NCIFP survey is designed to improve understanding of the policy and enabling environment for family planning, and was developed through a consultative process that included the FP2020 PME and Rights & Empowerment Working Groups, donors, and various implementation partners. With respondents from national family planning programs, NGOs, academic and research institutions, and international agencies, the survey attempts to measure the existence and implementation of policies, systems, and standards around quality, accountability, data use, equity, and strategy.
23. Sedgh G et al., Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/unmet-need-for-contraception-in-developing-countries
24. Survey data from Pakistan represents married women only.